GreenShield is a proudly Canadian, national non-profit health care and insurance organization, driven by our mission of Better Health for All. We believe health care is a right, not a privilege, and we are committed to improving health outcomes, advancing health equity, and building a future where every Canadian can reach their full health and well-being potential. Through our unique integrated payer-provider ("payvider") model,

we offer
insurance, administer benefits, and pay claims as a ‘payer’ while offering health care services such as mental health, pharmacy, telemedicine, and chronic disease management as a ‘provider’. As a non-profit social enterprise without shareholders, we reinvest our excess earnings to directly support underserved communities. What’s driving us now is the commitment to measurably impact an additional three million Canadians by 2030 – across mental health, essential medicines, and chronic disease management – through scalable initiatives that deliver meaningful change in pursuit of our mission of Better Health for All. At GreenShield, our culture is where purpose meets passion and performance. Our teams work as one to deliver meaningful, measurable impact for the people and communities we serve. WHO WE AREWhen it comes to health, we’re always looking for ways to push for better. We’re the only not-for-profit social enterprise that brings worlds of coverage and care together, all in one place. We’re noble challengers, purposefully building a better way and we need the best people to help us create a more holistic approach that takes care of the mind and body. Our mission is to create better health for all Canadians, and we know that starts with our employees. THE ROLE IN A NUTSHELLWe are seeking a strategic and analytical Claims Management Manager,



responsible for building and executing a comprehensive claims oversight framework that enhances financial integrity, operational efficiency, and member experience. This individual contributor role will serve as a key enterprise resource, driving initiatives across auditing, anomaly detection, and adjudication optimization. The Manager will collaborate with finance, pricing, fraud, automation, and product teams to identify cost drivers, mitigate risks, and ensure claims processes align with organizational objectives and industry benchmarks. Claims Oversight and AuditingEvaluate existing plan designs for gaps or inefficiencies and recommend enhancements such as Health Spending Accounts (HSAs), maximums, and prior authorization criteria.
Conduct regular audits of plan setup in administrative systems to ensure accurate adjudication logic.
Build predictive models for high-cost claims, chronic disease prevalence, and utilization patterns.
Develop scenario analysis for catastrophic claims and emerging health risks.
Analyze Customer Relationship Management and Claims Data Management data to detect unusual claims activity and feed insights into fraud detection and plan design workflows.
Strategic Reporting & InsightsDevelop dashboards for claims trend by claim type and provide actionable intelligence to leadership.
Deliver quality insights on cost drivers and emerging risks.




Root Cause Analysis and Rule OptimizationPerform deep‑drive investigations into transactional data to identify adjudication rule gaps.
Ensure commission recovery processes align with claims adjustments. Fraud, Waste, and Abuse CollaborationWork closely with fraud teams to analyze recovered cases and integrate insights into claims workflows.
Explore partnerships with external fraud analytics vendors to strengthen detection capabilities. We’re looking for a unique individual with a big brain and a big heart who wants to help us create better health for all Canadians. Bachelor’s degree in Finance, Mathematics, Data Analytics, or a related field. Master’s degree would be an asset.5+ years of experience in claims management, health benefits, or insurance operations.
Solid analytical and investigative skills with the ability to interpret complex data and identify actionable insights.
Proficiency in data analysis tools and platforms (SQL, R, Tableau, Power BI).
Being intentionally inclusive of diverse backgrounds, perspectives and experiences will enhance our company culture to positively impact how we support our communities. A career at GreenShield isn’t just about personal achievements, it's about making a difference together. Proficiency in English is required for this position. As part of this role, you will be required to communicate with colleagues or customers who use English as their primary language. By requiring English proficiency for this position, we aim to ensure that our employees can excel in their roles, collaborate, and communicate effectively, and contribute to the success of our organization. GS supports diversity, equity and inclusion in our teams and communities, and we value the unique contributions made by all. We encourage applications from all

📌 Manager, Actuarial Claims Strategy (Canada)
🏢 GreenShield
📍 Canada